Friday, September 21, 2012

There are a couple of things that went on I wanted to tell you about from the Florida Academy of Cosmetic Dentists meeting I went to. This was my forth meeting.

I get a lot of emails from them telling me what is going on in the group. They are very professional and not overbearing. There are guys two guy who are always there. They are both past presidents and they are always in magazines. They are like the faces of the group.

Taking a step back here, I think this economy has hit cosmetic dentists the hardest. They do one thing: high-end, cosmetic, elective dentistry. Of course, when the economy is tough, this is the first type of dentistry that is going to be put off. I know this. And for this reason, I am glad I am a jack of all dental trades. I think I am pretty good at a lot of things. I do root canals.

I do anterior esthetics, composites, porcelain veneers.

I work on kids. I do removables (as little as possible). I do posterior composites pretty well. I do full-mouth reconstructions. I restore implants. My father does the Invisalign in the office. We do a lot of things. So when the cosmetic stuff decreases, you know what increases? Root canals. Because people ignore that hole in their tooth until it starts to hurt. When it hurts, I am their man. And when the cosmetic stuff comes back and they are ready to change their smile, again, I am their man.

I am not saying that I don't understand why someone would move their practice toward doing one thing well. I do. I just like a variety in my life. I like all those aspects of general dentistry (except for the removable part).

Now, back to the guys I was talking about. Some of us were talking about work and whatnot. Of course, the conversation got to how busy we are or are not. It was all about how slow we all are. We were not complaining; the overarching theme to our conversation was how blessed we all are to have this awesome job. One guy did, however, talk about how he was considering taking plans. "Yeah, you know Dr. X and Dr. Y over there? I practice near them and their office started taking plans."

I don't know. I think this does two things. It justifies how we are doing. If the guys writing magazine articles are slow, then I guess it makes me feel a little better that I am less than packed. And if they are taking plans then I guess it might not be such a terrible thing. It gives us confidence to maybe call up the representative.

The guy I was talking to said that he is getting so slow during the summer months that he has had the insurance representatives in the office. He said there are people you can hire to be an advocate for you. They will call the insurance people and either negotiate a fee or they will find what is in your wheelhouse and find the insurance plan that fits you and your office the best so you don’t take such a hit.

A couple of months ago, our office called in a representative of what we thought was the most used and best insurance plan in our town. We had a discussion with her. We almost bit the bullet until we found out that it was not just the new people we would have to honor the plan’s fees for but that our existing patients would have to pay more to see us. The dollars lost because of that was enough to run the rep right out of the office. For an established office like ours, getting plans is a tough sell. Have any of you started taking plans? I would like to hear about it.

There was another thing that I found interesting in the lecture. This was a high-end lecture. This guy does very high-end Pankey/Dawson type dentistry. You know, full-mouth reconstruction, multiple discipline treatment plans. I have seen many of these practitioners; he is the first one that said that you don't have to do this type of dentistry on all of your patients.

I am a very big fan of Pankey, so I am not knocking them under the bus. But I have always had a beef with the Pankey system: if you are going to workup everyone that walks in your office, you are going to scare a lot of people and watch them walk out. This dentist said that if you are only going to restore one tooth, just do it. You have nothing to worry about. You don't need to know about the VDI or the CR or the MCO. I have always felt a little inadequate when I broke the Pankey mold, but he is saying it is okay. Good, because I have about 400 single-unit crowns out there.

I feel like being slow is the norm around our offices. I am happy when I am busy, but I am not all that sad when I am not. Look, I get to write blogs and articles and whatnot. I am not feeling inadequate. The overwhelming feeling I get when I think about all this gratitude. You know, blessed.

Hey, if the president of the FACD is taking plans and the Pankey/Dawson guy is saying it is okay to do a crown, things are definitely changing.

Have a great weekend,

john

P.S. I write about these things because I know how easy it is to feel small. I have been there. I have read the magazines and seen all the dentists talking about how awesome their practices are. They are producing $2,000,000 and not even breaking a sweat. They only had to do X and it changed their lives. I hope this helps. You’ve got a great practice with great patients. Feel blessed.

Wednesday, September 19, 2012

Hope you all had a great weekend. I sure as heck did with the Fighting Gators beating up on the Tennessee Volunteers. Not that we are overlooking the Kentucky Wildcats (who lost to Western Kentucky at home), but we have a date with destiny in two weeks when we play LSU!

I am so pumped about this game that I looked up an old video that gets me going every time. I laugh every time I watch this video. "Can't Wait" went absolutely viral after this video. There were billboards, T-shirts, the whole 9 yards. I love it.

I went to the Florida Academy of Cosmetic Dentistry meeting this weekend. I really like this meeting. It is small, but they always have very good speakers and very good dentists and labs there. This year they brought over two guys from Italy. I missed the first guy, but the second guy was really good. He was really polished, his slides were awesome, and his pictures were crazy good. His slide transitions were perfect.

As a pseudo-presenter, I look at that stuff and wonder how he does it. He must either be some sort of computer genius or hire this stuff out. So while I was listening to the content of the lecture, I was also marveling at the quality of the whole presentation.

I was milling around the exhibit hall during a break. I turned around and speaker was hanging out right behind me. I have no problem asking people about anything, so I started the inquisition by telling him how much I was enjoying his lecture. I told him how well the thing was put together. I told him I am a budding presenter and that looking at his stuff tells me how much work I have to do.

I asked if he has a company that helps him with his lecture and was shocked when he told me that he does it all himself. How does he do it? He works from 8 a.m. until about 5 p.m. Then he starts working at his computer and gets home at about 9 p.m. He has dinner and then works again until midnight.

I asked him if he is married because this wouldn't fly at my house. He is married. Well he must not have any children, right? Wrong. He has three children, ages 14, 16 and 18. I work until 4 p.m. Then I take off my dentist hat and put on my dad/coach/carpool driver/wrestler hat. He doesn’t do any of that. He implied that his wife is not really happy with his schedule.

I was really shocked. He is husband and a father but he is totally selling out to dentistry. I am going to tell you how I feel about this stuff. It may sound very different than how you feel. I value your opinion and would love to hear how you feel about this.

I feel sorry for him. I feel sorry for his wife his kids. My primary job in life is being a dad and doing the best I can to raise my children. A close second is being a great husband. The kids are all going to go away (16 long years from now) and all my wife and I are going to have is each other. Coming in third place is dentistry.

Look, I love my job. I love people. I love teeth and fixing teeth and giving people the smile they have always dreamed of. I totally jump out of bed because I can't wait to go to work (okay, that might be a slight exaggeration). But it pales in comparison to job one and job two.

I always talk about perspective. I think a well-rounded dentist is a great dentist. I can relate to my patients who have families. I can relate to my patients who have small businesses. I can relate to my patients that coach or are involved in church. I can relate to them in so many ways because I do all of that.

It is a shame that we can't be great at everything. Being great takes a lot of time. And because there isn't enough time to be great at all things, you almost have to choose. I think you can be great at a couple of things. I mean, I think I am a great dentist and a great blogger. Don't you think that? I would say my kids think I am a great dad and I think my wife would say I am a pretty good husband. Do I screw up sometimes? Yes. Do I overbook my schedule? Yes. Do I feel like my head is spinning most of the time? Yes. But if we have to choose, what are you going to choose? Is it going to be teeth over your kids? I hope not.

Is this what we want as professionals? Do we care about our speaker’s family life? Do we really want our teachers to hole themselves up in a computer room and work on their presentation all night? Do we really want them neglect everything else? I don’t think they can relate to me if they do dentistry 75 hours a week without any family responsibilities.

I want a guy that struggles with time management too. I want a guy that has tons of work to do but goes home anyway because his son has a T-ball game or his daughter’s dance recital that he can't miss. I don't know. I want the person teaching me to be smart and knowledgeable, but I want them to be like me, too.

I was sitting next to a friend at lunch talking about this. He said that he wants a guy that has sold out for dentistry. I think is a cop-out. I think the guy can do both. He can be a good dad and a good husband and still be awesome at teaching. It can be done. And if it can't be done, then I think the guy made the wrong choice.

Friday, September 14, 2012

It is official. I have purchased 100% of my practice. I have been making pretty much all the decision around here for the last couple of years (my dad did a good job giving me the reins little by little), but the weight of the whole thing seems heavy. Nothing has changed, but knowing that it is all mine has been shockingly burdensome. I have worked so hard for this. I have been chasing after this dream and now that I finally have it, it just is weird.

One of the gals I run with owns a retail store. She recently let an employee go because he was stealing cash. He is 65 years old and had been with the company for 36 years. It is a family-run store and he started when my friend’s father was the owner. He has been to all the weddings, baptisms and BBQs the family had. He was part of the family. Wow. Does this make you think?

I started to think about tightening up my ship, money-wise. This may sound weird, but I don't look at a day sheet. I look at the schedule in the morning and make a mental note of how it looks. I can judge the production pretty well. I know that if everyone comes today this will be a really good day. Some days, I hope someone comes in with an emergency because nothing productive is going on. Then I realized that production doesn't mean as much as collection. So, this week, I asked for a daily sheet that has production and collections on it.

This sheet is absolutely meaningless. Let’s just say on Tuesday the office produced $1,000. Great. How much did we collect? $240. Then the next day, we produced $1,000 and collected $3,800. I found tracking collections is very difficult. We are a fee-for-service office and we take traditional insurances (80/20), but still so much depends on insurance checks. We might do a crown one day and not get paid for a couple of weeks. So, what good is looking at the collections?

While doing all this, I started to think about something. I get the audit sheet once a month. This is a list of all of the folks that owe us money. Eighty percent of them are outstanding insurance. That means that if someone had a crown done, we charged them half knowing that they have insurance. The insurance check hasn't come in yet, so they get put on this list. Twelve percent of these people we have arrangements with. Someone might not have been able to afford the procedure, but we did it anyway knowing that collecting would not be an issue. And about 5% or so are people that really owe us money. There are 30-, 60- and 90-day columns.
On this list, my staff notes what is going on with each person. If an amount is over say, $500, I will look at this line item. If I see she has an “INS” by the name, we are just waiting for insurance. I know she is on it.
If there is a “DLQ” by the name, they have been sent to collections.

Then there are the ones that I know have moved because they have lost their job. They foreclosed on their house. They had to sell the car to buy a van they could live in. And we have been hounding them for $178 for 14 months. I will say just write this off. There comes a time when it just isn't worth it. The man-hours, the stamps, the phone calls, the letters. For $53, how long do you hold on to this stuff? I mean, they were paying $5 a month for 2 and a half years and then the $5 stopped coming. Just write it off.

The blog was not going to be about this stuff. When I realized I am now 100% owner, I started to think.
My person up there, the one collecting the money, the one I trust whole-heartedly, could really be robbing me blind and I wouldn't know it. There are checks and balances here, but there are still holes the size of California in our systems.

I started to think how she could be doing it. She could be doing it collections. There really is no way to check. Say Mr. Bill comes in and gets a crown. The day of prep he pays $500. The insurance request goes out. He owes us $700. The audit sheet shows Mr. Bill owes $700 with “INS” next to it. Let’s say the insurance pays $500. The next month, the audit sheet shows Mr. Bill owes $200, and there is a check mark next to it meaning she is on it. Mr. Bill comes in and pays $200 in cash. She zeroes his account out and puts $200 cash in her pocket. No one knows. How do you prevent this? Cameras?

I have already told you that I am a NOT a micromanager. I am pretty happy that I am looking at the day sheet. That was a big step. But me going further? Ughhh. As I write this, I think there must be a "write off" line item. I think when she writes things off and hits "enter," it goes to a place on EagleSoft and this could something I could check.

I can't collect myself. I have to have someone do it. I have to trust. I have to look at the sheets, but I have to trust in the person putting the sheets together. I don't know. I feel like the woman that does my collecting is part of my family. She has been here about 13 years. Hmm. This is starting to sound like my running friend’s story.

I trust my person up there, but I know everyone who gets money embezzled feels the same way. My assistant tells me that this person is the last person who would steal from me. But these are famous last words. I am not accusing anyone. I am not even suggesting that it is happening here. I am saying that it does happen and it is usually people that you trust the most and you let your guard down.

What do you guys think? Do you have checks and balances? Do you put your head in the sand a bit? Or are you the Gestapo? Let me know. Then have a great weekend.

I am running 22 miles tomorrow morning, then sitting on the couch and watching the Gators play Tennessee. Wish me luck on both.

Wednesday, September 12, 2012

Well, if you didn't notice, we were off last week. I hope you missed us.

I want to talk about the “Sorry” patient. This is not a patient who apologizes to you. This is the patient you have to apologize to. I want to talk about the appointment that should be easy but just doesn't go so well.

Let’s say a patient comes in for 18 occlusal. I have 20 to 30 minutes in my schedule. I want this patient in and out and thrilled when he is done. "Wow, I didn't even feel that. That was so easy. Thanks." This is not even a blip on the radar for either of us.

I greet the patient and tell him that he has a cavity on the back tooth that is right in my wheelhouse. It is my bread and butter and I do it all the time. I tell him we’ll get this tooth numb and he will be out of here in a jiffy.

I usually will not do a block here. For one posterior in the mandible, I will try to use the Paroject injection system (an interligamentary injection) and put Septocaine all around the tooth locally. I want this to be a fast appointment and I don't want my patient numb for two to three hours for a 10-minute procedure.

When we begin, I tell the patient to let me know if he feels anything. I start in on the tooth and he jumps, so I back off. Did I not give the anesthetic enough time to work? Do I cut bait and go for a block? I grab the Paroject again and pump more anesthetic in and around the tooth. (For the record, the Paroject system works about 95% of the time. There are times it doesn't work, but it has been very successful for us.)

I start again. Have you started to sweat yet? You know how this is going to go. I am starting to sweat just telling you about the story, because I know what is coming up.

Almost immediately, he jumps. "Hmm," I say out loud. “Sorry about that. I guess we are going to have to give you a block." My assistant, who saw this coming, has already gotten out the Lidocaine in a syringe, and I give the patient a block.

Now I am 25 minutes into my 30-minute appointment. Oh, and it never fails that I have already had a pretty crappy day, so this is just piling on. But all is not lost. I can get the patient numb and get this thing done, right? Not so fast. The patient is numb in the back, but there is no tingling on the lip or tongue. My assistant already has another injection ready. I inject again, this time higher and lower and farther back and farther up. I have lost a bit of discretion because I just want him numb.

I don't wait this time and go right in with the handpiece. The patient can handle it, so I take the old filing out and see the decay. I touch the tooth and he jumps. He is starting to get a bit impatient. "Just go ahead; it is not that bad."

I go a little bit more and he is trying hard not to move, but I can tell he is feeling it. I am now officially running late and don't even have the patient numb yet. I tell some jokes to pass the time then go check on hygiene because all the hygienists have been loitering around the door for the last 10 minutes. I come back with a renewed sense of calm, ready to get this done and get him out of here. Feeling confident, I ask him how the numbness is. When he says he thinks his lip is a little tingly, we try again.

I start again and I am able to go a bit more, but I know that if I try to get all the decay that I can see, it is going to hurt. I tell him that I have this one spot to get and it is going to take just a couple of seconds. He understands, but meanwhile, I might see a tear or sweat on his forehead.

I officially hate my job. I hate doing fillings and I hate products that don't work. I am sweating. I yell for someone to turn the freaking air conditioner down. Nasty thoughts are running through my head. How many more years do I have to do this stuff before I can retire? I somehow get this procedure done.

AND the filling doesn’t even turn out well! How could it? I am under duress. I am 25 minutes behind and three of my next patients are here and waiting. Then I have to go to the front and charge him. UGHHHH.

At the end, I apologize that it didn’t go very well. You know what he says then. They always say this. You know what he is about to say. "Man, I am SOOOO numb now!!!!"

I try to continue on with my day, but it lingers. I try to put it out of my mind. And just when, after a day or so, I have officially chalked this up to having a bad day, I get a phone call. In the back of my mind, I know who is on the phone. He is calling to tell me that I suck so bad I can't even get a guy numb. He has been in quite a bit of discomfort from all the injections and now can't open his mouth more than about an inch.

No, I don't suck as a dentist. Yep, it happens. It happens to me and it probably happens to you. It sucks though. If it hasn't happened to you, be prepared. It is going to happen to you.

Hope this makes you feel less alone and puts a little smile on your face. Yes, it happened to someone else.

Tuesday, September 11, 2012

Well, summer is officially over. We know this for several reasons. The Farmer's Almanac says so, football season is here (my Gators are going to need some help this year), and the kids are back in school. I love the fall here in Florida; it is still warm enough to swim but the humidity starts to die down and the mornings occasionally are a little cooler.

Do you think much about your retirement dreams? I do at times, even though I figure I have about 20-25 more years to go. That would put me at 59-64 years old. I figure I will work until I am 65 unless something changes that. “Sixty” sounds real nice to me; a good age to hang it up.

My parents recently bought a really nice cabin in Mineral Bluff, Georgia. There is biking, zip-lining, shopping, white water rafting, train rides, lots of fun stuff to do. They are renting it for about $1100.00 a week and it sleeps up to 10 people. It is really nice. It is for rent - email me if you want to see Evening Shade Hideaway. Anyway, it was their dream to have a mountain cabin. My dad is a retired brigadier general and he is using his Army retirement reserve check to pay the bills with some still left over. I will not have a nice government pension to rely on, so I have to save myself. That was one of their dreams, I guess.

What are yours? Mine is to just be able to maintain a comfortable existence. A beach place would be great. Do you have a retirement plan in effect and are you meeting your goals? Do you have a professional planner leading the way or are you on your own? I have done some of both. I know some people that spend $10k plus a year on a financial advisor. Too rich for my blood!

I do not bet on social security at all with the way this country is going. When I see the projections on how much I will need, it seems impossible. I still have three young kids to get out of the house and on their own two feet. That is my first goal, but I am trying to save for myself. I know I could do better, but I like to have toys now. Who knows if I will even make it to retirement to enjoy it? I am the type that always has to have a carrot hanging out in front of me to motivate me to work hard.

Do you think about 20 years down the road, or are you just trying to get done with the next patient?

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The purpose of The Daily Grind is to offer readers a glimpse into the life of general dentists practicing today. Each post offers a perspective on managing a dental practice or balancing a life outside of the practice. The Daily Grind is written by several general dentist and student members of the Academy of General Dentistry.

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